Sea King BoI report released

1 August 2007

By Julian Kerr

The Board of Inquiry (BoI) report into the Sea King helicopter crash on Nias Island in 2005 doesn’t make good reading; implementing its recommendations should make a recurrence far less likely but there are safety culture lessons needing to be re-learned.

A scathing Board of Inquiry report into the crash of a Royal Australian Navy (RAN) Sea King helicopter in Indonesia in 2005 has dealt a body blow to the safety reputation of the RAN’s aviation arm.

Not only did the 1,700-page report criticise what was described as an “embedded culture of shortcuts and workarounds” in the Aviation Group’s maintenance practices; it also referred to “a complex interaction of individual and systemic failings across the ADF and parts of the Defence Organisation”.

Tellingly, the report detailed no less than 256 recommendations, all of which have been accepted by government.
Major cultural change was required to improve naval aviation safety performance and to correct problems “which are probably common to some degree across the ADF aviation community.”

Nine ADF personnel died and two survived with severe injuries when the Sea King crashed and exploded in flames on the island of Nias in April 2005 while engaged in tsunami relief operations.

Cause and effect
The exhaustive BoI lasted 20 months, and found that the primary cause of the accident was a failure of the flight control system caused by separation of the fore/aft bellcrank from the pitch control linkages in the aircraft’s mixing unit.

The mixing unit couples and directs pilot control inputs to the main and tail rotor systems.
This separation was caused by the incorrect fitting 57 days earlier of a nut and split pin, something not detected because a quality inspection was not conducted.

While the report totally exonerated the Sea King’s four-strong crew, all of whom died in the crash, adverse findings were made against 10 ADF personnel who now face disciplinary action.

The personnel have not been named for legal reasons but are understood to range from senior officers to junior ratings. All but one are still serving.

The report has also been forwarded to the New South Wales coroner, who will decide whether any criminal charges will be laid.

Unscheduled maintenance activity by 817 Squadron Sea King Detachment (aboard HMAS Kanimbla) was characterised by a series of errors, oversights, inadequate supervision, repeated non-compliance with maintenance regulations, and poor communication and coordination within watches and at handover of watches, the report found.

Within 817 Squadron itself, maintenance error and non-compliant maintenance practices were recurrent and existed well before the accident, but were regarded as separate events.

“There was no recognition by squadron and senior command and management that these problems were intractable and there was no coordinated effort to address the problems systematically,” the report stated.

Culture issues
By November 2004 the Commanding Officer (CO) of 817 Squadron had identified an embedded culture of maintenance shortcuts and workarounds to the Capability Manager and to Maritime Headquarters but provided assurances that it was being managed.

“Those in the chain of command and capability management did not recognise the message in the common thread; that the initiatives and measures were actually not working and that intervention was required to support the CO in overcoming the Squadron’s problems.

“During this part of the Inquiry, it was apparent that senior commanders and managers did not fully understand their responsibilities for airworthiness and there was some confusion with regard to the relative roles and responsibilities of the ADF Airworthiness System authorities and agencies,” the report said.

The ADF’s systems support was not spared.
The Board commented that the RAN’s stated commitment to safety was not matched in practice.
Personnel did not understand the safety rationale behind many airworthiness rules and regulations.

The performance of most senior managers in managing 817 Squadron’s airworthiness standards airworthiness system was significantly affected by the support that the Airworthiness Management System provided.

Significant deficiencies were found in audit and surveillance processes and a review of the Airworthiness Management system was needed.

The report linked the existence and persistence of non-compliant squadron maintenance practices to competency issues with technical tradesmen, aircrew and managers at all levels.
At the same time, it highlighted safety deficiencies in the Sea King’s seating and restraint systems, internal structures and materials.

A history of neglect
Notwithstanding scientific studies, research and much effort over the 10 years before the accident, more crashworthy seats and harnesses had not been installed in the Sea King class of aircraft.
This was in spite of a recommendation by a Board of Inquiry investigating the crash of a RAN Sea King at Bamaga in Cape York in 1995 that such seats and harnesses be fitted.

“These deficiencies presented heightened impact, flail and toxic smoke hazards and impediments to escape. This directly affected the probability of survival of the occupants after the accident and contributed to the deaths of some of the seven occupants who appear to have survived the initial impact sequence.”

Detailed recommendations by the Board cover airworthiness, command control and communication, engineering and logistics, general administration and personnel, maintenance management, operations, safety, and aviation training.

They include a review by the Maritime Commander Australia of Navy Aviation squadron command and control arrangements, and the establishment by the Commander of the Naval Air Group of guidelines for the conduct of comprehensive and timely management audits.